My professional response to this question is molded by 25 years
of experience as a nurse, while my personal response grows out
of having been at the bedside of my parents as they died.

My 49-year-old mother was stricken with a massive heart attack
and succumbed in an intensive care unit, after eight hours of
invasive, barbaric, yet appropriate, care that was aimed at saving
the life of this loving, vibrant woman. Her poor body died, only
after the needles, tubes, pumps, and ventilator were removed.
I remember staring at her feet, the only part of her body that
I could connect with the mother who had held and loved me.

We were allowed back into the room only after the machinery was
removed and her heart was no longer beating. There was nothing
dignified about her dying, except the fact that she was allowed
to do so. My head knows that this is the way in which her death
needed to play out. My heart wishes it could have been different.

Ten years later, my dear 67-year-old father took his last breath
with his family at his side. While his two-year battle with laryngeal
cancer was filled with its share of dehumanizing and ultimately
futile treatments, such as surgery and radiation, his peaceful
death, on a hospice unit in Minneapolis, was a world apart from
the horrors of my mother's last hours. I witnessed, firsthand,
the special "midwifery" of professionals who know how to guide
the passage from this life.

Are the people who die in intensive care units a completely different
set of patients? I believe they are not.

Many people who die in this nation's intensive care units could
die at home or on a palliative care or hospice unit. Because we
demand it and/or doctors suggest it, even the chronically and
terminally ill find themselves in intensive care units. It is
the feeble hope of prolonging life that puts these poor souls
in line for a miserable, undignified death, while their families
are huddled in sterile waiting rooms.

What needs to change? Physicians must be empowered and trained
to refuse to provide futile care. Hospitals should provide low-tech
palliative care for those who are dying within their walls. This
nation's 2,200 hospice programs must continue to assist families
to provide for a home death whenever possible. As individuals
and as a public we must come to accept the normalcy and inevitability
of death.

And so the answer to the question is "yes." Images of intensive
care deaths will haunt daughters for as long as they continue
to occur.

John Hansen-Flaschen, M.D.

People enter ICUs not to die, but to live. Whether the patient
is a school girl struck down by a bus, a mother afflicted by a
run-away pneumonia, or a grandfather threatened by a complication
of surgery, the primary purpose of intensive care is to fight
off death and restore health. Like fire fighters, critical care
specialists are often successful in averting catastrophe. But
we do not always succeed, and we can cause great damage by our
efforts.

Recently, much attention has focused on the experience of dying
in an ICU. Research studies paint an unattractive picture. Some
families report fear, miscommunication, and indifferent or inconsistent
care. Many ICU patients appear to suffer pain or breathlessness
in their final days of life. Their bodies end up bruised and swollen
as if they died out on the street.

It does not have to be that way. When a patient fails intensive
treatment, an enlightened ICU staff can shift from life support
to comfort care. By removing some of the tubes, shutting off the
monitors and turning down the lights, we can convert an ICU into
a well-attended bedroom or a chapel that a family can make their
own. At $2,000 to $5,000 a day, the best ICUs can (and do) provide
the best hospice care available anywhere.

Should you fear death in an ICU? Only in the wrong ICU.

How can we ensure appropriate intensive care for ourselves and
our family members?

First, ask these two questions before sending a loved one to
an ICU. (1) Does your family member want to continue living, even
if the personal price is high? (If the person is so severely ill
or impaired that he or she can never again express thanks for
being alive, the answer is probably no). (2) Does he or she have
a reasonable chance of recovering from a critical illness? (If
the person is frail and elderly, or suffers from a severe, chronic
or terminal illness, the answer is likely to be no).

Second, be there with the patient in the ICU for at least several
hours every day. Physicians and nurses tend to do their best for
uncommunicative, critically ill patients when the family is present
at the bedside.

Third, expect attentive care and effective communication. Many
people do not understand that they can choose their hospital,
even under desperate circumstances. In major metropolitan areas,
most critically ill patients can be transferred safely within
hours by ground or air ambulance to a regional referral ICU at
the request of the family.

Fourth, be prepared to let go when a trustworthy doctor advises
that the battle is lost. Too many patients suffer on in ICUs at
the insistence of well-intentioned but misguided families who
believe it is their duty never to "give up." When the time is
right, letting go is not an abandonment but a gift.

Connie Holden, R.N., M.S.N., is the Executive Director of Hospice of Boulder County, Boulder,
Colo. She sits on a variety of ethics committees and serves on
the Colorado Governor's Commission on Life and the Law, the International
Work Group, and the National Prison Hospice Association. Connie
can be reached at Hbcholden@aol.com

John Hansen-Flaschen, M.D., is Chief of the Pulmonary and Critical Care Division and Director
of the Comprehensive Lung Center at the University of Pennsylvania
in Philadelphia, Pa. Dr. Hansen-Flaschen practices critical care
medicine in the regional referral medical intensive care unit
at his hospital. He also lectures and writes about ethical issues
in medical intensive care and decisions near the end of life.